Provider Demographics
NPI:1477702835
Name:BURGESS, MATTHEW EVAN (OD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:EVAN
Last Name:BURGESS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5913
Mailing Address - Country:US
Mailing Address - Phone:505-321-6703
Mailing Address - Fax:
Practice Address - Street 1:2855 MAIN AVE
Practice Address - Street 2:STE A103
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5956
Practice Address - Country:US
Practice Address - Phone:970-382-8970
Practice Address - Fax:970-382-8966
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2950152W00000X
NM628152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87787857Medicaid